Healthcare Provider Details

I. General information

NPI: 1831940352
Provider Name (Legal Business Name): CAROLINE ANNE ZIDELL CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 W COSSITT AVE
LA GRANGE IL
60525-2145
US

IV. Provider business mailing address

228 HOLMES AVE
CLARENDON HILLS IL
60514-1418
US

V. Phone/Fax

Practice location:
  • Phone: 708-354-5730
  • Fax:
Mailing address:
  • Phone: 817-875-2243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number146017575
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: